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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920201
Report Date: 06/06/2025
Date Signed: 06/06/2025 03:50:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/30/2025 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250530084909
FACILITY NAME:LEGACY LANE SENIOR LIVING IIFACILITY NUMBER:
345920201
ADMINISTRATOR:GARDINER, CLEOPATRAFACILITY TYPE:
740
ADDRESS:3039 WALNUT AVETELEPHONE:
(564) 200-1736
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
06/06/2025
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Moria Gaunavou, AdministratorTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Licensee is not addressing pest infestation.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Moria Gaunavou, to open a complaint investigation into the allegation listed above. LPA also spoke to Administrator, Cleopatra Gardiner, via telephone call during visit.

During the investigation, LPA conducted interviews, toured the premises, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Licensee is not addressing pest infestation.

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 59-AS-20250530084909
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LEGACY LANE SENIOR LIVING II
FACILITY NUMBER: 345920201
VISIT DATE: 06/06/2025
NARRATIVE
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During visit conducted on June 6, 2025, LPA toured the premises, including kitchen/living room area, resident bedrooms, staff bedroom, and perimeter of the care home. LPA observed at least a dozen live flies in the kitchen/living room area and multiple dead flies in the kitchen/living room area. LPA also observed dead flies in two (2) resident bedrooms. Interviews with staff members S1 and S2 acknowledged the large amount of flies inside the facility. S1 stated that one (1) resident will leave their outside bedroom door open and cause flies to enter the home.

LPA observed roach traps in one (1) resident bedroom. Interview with S1 indicated that roach traps were purchased and placed by resident.

Interview with S1 and residents (R1 & R2) indicated that they have witnessed roaches inside the facility. Interview with R2 also indicated witnessing spiders inside the facility. Interview with Administrator Gardiner indicated that the last time they have had pest control conduct treatment at the facility was prior to the license being issued. Administrator Gaunavou provided LPA with an invoice dated May 21, 2025 indicating that pesticide treatment for roaches, flies, and lizards was conducted. S1 and R1 indicated observing roaches after treatment conducted on May 21, 2025. Licensing is requesting facility contract with a pest control service for regular treatment to address ongoing infestation.

Based on LPA's observations, interviews conducted, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250530084909
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LEGACY LANE SENIOR LIVING II
FACILITY NUMBER: 345920201
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2025
Section Cited
CCR
87555(b)(27)
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87555 General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
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Facility will contract for regular pest control services to address pest infestation, including, but not limited to, roaches and flies. Facility will provide proof of service regarding first treatment for flies and roaches by POC due date of 6/13/2025.
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Based on observations and interviews conducted, the facility did not ensure that the kitchen area was free from insects, which poses a potential health, safety, and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
LIC9099 (FAS) - (06/04)
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